{"id":5053,"date":"2024-07-10T10:21:13","date_gmt":"2024-07-10T08:21:13","guid":{"rendered":"https:\/\/radiologie.aretis-staging.ch\/?page_id=5053"},"modified":"2025-03-06T09:35:28","modified_gmt":"2025-03-06T08:35:28","slug":"referrer-forms","status":"publish","type":"page","link":"https:\/\/radiologiezentrumbaden.ch\/en\/kontakt\/zuweiser-formulare\/","title":{"rendered":"Referrer forms"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5053\" class=\"elementor elementor-5053\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d8865c2 e-flex e-con-boxed e-con e-parent\" data-id=\"d8865c2\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-06ead83 e-con-full e-flex e-con e-child\" data-id=\"06ead83\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-496c1a9 elementor-widget elementor-widget-heading\" data-id=\"496c1a9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Anmeldung online oder per PDF<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-dfd6036 elementor-widget elementor-widget-heading\" data-id=\"dfd6036\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Zuweiser - Formulare<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8f506f3 e-flex e-con-boxed e-con e-parent\" data-id=\"8f506f3\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-1ef4be3 e-flex e-con-boxed e-con e-child\" data-id=\"1ef4be3\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-2d4c869 e-flex e-con-boxed e-con e-child\" data-id=\"2d4c869\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-077e346 elementor-widget elementor-widget-heading\" data-id=\"077e346\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Patienten-Anmeldeformulare<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b67f366 elementor-widget elementor-widget-text-editor\" data-id=\"b67f366\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Die Formulare lassen sich direkt am Computer ausf\u00fcllen. Sie k\u00f6nnen sie bequem anklicken oder herunterladen und direkt ausf\u00fcllen.\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-57006d0 e-con-full e-flex e-con e-child\" data-id=\"57006d0\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-a984a47 e-con-full e-flex e-con e-child\" data-id=\"a984a47\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6668425 elementor-view-framed elementor-shape-square elementor-widget elementor-widget-icon\" data-id=\"6668425\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2025\/02\/Anmeldung-NEU-14.2.25.pdf\" target=\"_blank\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 249.76 231.83\"><g transform=\"translate(-198.5 -144.43)\"><path d=\"m323.39 376.2c-23.46 0-46.91.14-70.36 0-25.77-.18-46.91-17.13-52.86-42.23a52.2 52.2 0 0 1 -1.55-11.3c-.19-13.46-.11-26.92-.06-40.38 0-6.36 3.21-10 8.5-10.06 5.56 0 8.54 3.37 8.56 9.89v37.89c0 22.88 16.17 39.22 39.19 39.3 39.75.12 79.51 0 119.26 0 7.48 0 15 .18 22.44-.29 19-1.2 34.36-17.54 34.59-36.61.15-13.29 0-26.59 0-39.88 0-6.85 3-10.4 8.66-10.33 5.4.06 8.39 3.59 8.4 10.1 0 13.46.09 26.92 0 40.38-.23 28.93-24.42 53.22-53.44 53.47-23.72.21-47.55.05-71.33.05z\"><\/path><path d=\"m331.77 290c15.66-15.65 30.1-30.1 44.55-44.53 5.93-5.93 10.92-6.81 14.91-2.67 3.74 3.88 2.72 8.87-3 14.58l-57.46 57.46c-5.13 5.14-9.44 5.28-14.5.23q-29.82-29.75-59.57-59.58c-4.08-4.1-4.43-9.24-1-12.8s8.7-3.24 13.11 1.15q20.85 20.75 41.63 41.57a32.83 32.83 0 0 1 3 4l1.67-.72v-5.55q0-64.29 0-128.57c0-7.22 3.05-10.58 9.11-10.13 4.43.32 6.94 2.83 7.46 7.2a45.32 45.32 0 0 1 .13 5.47v132.89z\"><\/path><\/g><\/svg>\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fca74e2 elementor-widget elementor-widget-icon-box\" data-id=\"fca74e2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2024\/09\/anmeldung_allgemein_fillable.pdf\" target=\"_blank\" >\n\t\t\t\t\t\t\tPatientenanmeldung (PDF)\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tAusf\u00fcllbare PDF-Datei\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-6dbc5cd e-con-full e-flex e-con e-child\" data-id=\"6dbc5cd\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7eea16c elementor-view-framed elementor-shape-square elementor-widget elementor-widget-icon\" data-id=\"7eea16c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2025\/02\/Anmeldung-NEU-14.2.25.docx\" target=\"_blank\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 249.76 231.83\"><g transform=\"translate(-198.5 -144.43)\"><path d=\"m323.39 376.2c-23.46 0-46.91.14-70.36 0-25.77-.18-46.91-17.13-52.86-42.23a52.2 52.2 0 0 1 -1.55-11.3c-.19-13.46-.11-26.92-.06-40.38 0-6.36 3.21-10 8.5-10.06 5.56 0 8.54 3.37 8.56 9.89v37.89c0 22.88 16.17 39.22 39.19 39.3 39.75.12 79.51 0 119.26 0 7.48 0 15 .18 22.44-.29 19-1.2 34.36-17.54 34.59-36.61.15-13.29 0-26.59 0-39.88 0-6.85 3-10.4 8.66-10.33 5.4.06 8.39 3.59 8.4 10.1 0 13.46.09 26.92 0 40.38-.23 28.93-24.42 53.22-53.44 53.47-23.72.21-47.55.05-71.33.05z\"><\/path><path d=\"m331.77 290c15.66-15.65 30.1-30.1 44.55-44.53 5.93-5.93 10.92-6.81 14.91-2.67 3.74 3.88 2.72 8.87-3 14.58l-57.46 57.46c-5.13 5.14-9.44 5.28-14.5.23q-29.82-29.75-59.57-59.58c-4.08-4.1-4.43-9.24-1-12.8s8.7-3.24 13.11 1.15q20.85 20.75 41.63 41.57a32.83 32.83 0 0 1 3 4l1.67-.72v-5.55q0-64.29 0-128.57c0-7.22 3.05-10.58 9.11-10.13 4.43.32 6.94 2.83 7.46 7.2a45.32 45.32 0 0 1 .13 5.47v132.89z\"><\/path><\/g><\/svg>\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a2308f0 elementor-widget elementor-widget-icon-box\" data-id=\"a2308f0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2024\/09\/Anmeldung-allgemein.docx\" target=\"_blank\" >\n\t\t\t\t\t\t\tPatientenanmeldung (Word)\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tAusf\u00fcllbare PDF-Datei\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8730f5d e-con-full e-flex e-con e-child\" data-id=\"8730f5d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-8d550c8 e-con-full e-flex e-con e-child\" data-id=\"8d550c8\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fcea2a1 elementor-view-framed elementor-shape-square elementor-widget elementor-widget-icon\" data-id=\"fcea2a1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2025\/02\/CT-deutsch.pdf\" target=\"_blank\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 249.76 231.83\"><g transform=\"translate(-198.5 -144.43)\"><path d=\"m323.39 376.2c-23.46 0-46.91.14-70.36 0-25.77-.18-46.91-17.13-52.86-42.23a52.2 52.2 0 0 1 -1.55-11.3c-.19-13.46-.11-26.92-.06-40.38 0-6.36 3.21-10 8.5-10.06 5.56 0 8.54 3.37 8.56 9.89v37.89c0 22.88 16.17 39.22 39.19 39.3 39.75.12 79.51 0 119.26 0 7.48 0 15 .18 22.44-.29 19-1.2 34.36-17.54 34.59-36.61.15-13.29 0-26.59 0-39.88 0-6.85 3-10.4 8.66-10.33 5.4.06 8.39 3.59 8.4 10.1 0 13.46.09 26.92 0 40.38-.23 28.93-24.42 53.22-53.44 53.47-23.72.21-47.55.05-71.33.05z\"><\/path><path d=\"m331.77 290c15.66-15.65 30.1-30.1 44.55-44.53 5.93-5.93 10.92-6.81 14.91-2.67 3.74 3.88 2.72 8.87-3 14.58l-57.46 57.46c-5.13 5.14-9.44 5.28-14.5.23q-29.82-29.75-59.57-59.58c-4.08-4.1-4.43-9.24-1-12.8s8.7-3.24 13.11 1.15q20.85 20.75 41.63 41.57a32.83 32.83 0 0 1 3 4l1.67-.72v-5.55q0-64.29 0-128.57c0-7.22 3.05-10.58 9.11-10.13 4.43.32 6.94 2.83 7.46 7.2a45.32 45.32 0 0 1 .13 5.47v132.89z\"><\/path><\/g><\/svg>\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-31ac8da elementor-widget elementor-widget-icon-box\" data-id=\"31ac8da\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2024\/09\/ct_fragebogen_deutsch_fillable.pdf\" target=\"_blank\" >\n\t\t\t\t\t\t\tCT-Fragebogen (PDF)\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tAusf\u00fcllbare PDF-Datei\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-2a452b5 e-con-full e-flex e-con e-child\" data-id=\"2a452b5\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-112a03b elementor-view-framed elementor-shape-square elementor-widget elementor-widget-icon\" data-id=\"112a03b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2025\/02\/MR-Fragebogen-Metarad-DEU.pdf\" target=\"_blank\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 249.76 231.83\"><g transform=\"translate(-198.5 -144.43)\"><path d=\"m323.39 376.2c-23.46 0-46.91.14-70.36 0-25.77-.18-46.91-17.13-52.86-42.23a52.2 52.2 0 0 1 -1.55-11.3c-.19-13.46-.11-26.92-.06-40.38 0-6.36 3.21-10 8.5-10.06 5.56 0 8.54 3.37 8.56 9.89v37.89c0 22.88 16.17 39.22 39.19 39.3 39.75.12 79.51 0 119.26 0 7.48 0 15 .18 22.44-.29 19-1.2 34.36-17.54 34.59-36.61.15-13.29 0-26.59 0-39.88 0-6.85 3-10.4 8.66-10.33 5.4.06 8.39 3.59 8.4 10.1 0 13.46.09 26.92 0 40.38-.23 28.93-24.42 53.22-53.44 53.47-23.72.21-47.55.05-71.33.05z\"><\/path><path d=\"m331.77 290c15.66-15.65 30.1-30.1 44.55-44.53 5.93-5.93 10.92-6.81 14.91-2.67 3.74 3.88 2.72 8.87-3 14.58l-57.46 57.46c-5.13 5.14-9.44 5.28-14.5.23q-29.82-29.75-59.57-59.58c-4.08-4.1-4.43-9.24-1-12.8s8.7-3.24 13.11 1.15q20.85 20.75 41.63 41.57a32.83 32.83 0 0 1 3 4l1.67-.72v-5.55q0-64.29 0-128.57c0-7.22 3.05-10.58 9.11-10.13 4.43.32 6.94 2.83 7.46 7.2a45.32 45.32 0 0 1 .13 5.47v132.89z\"><\/path><\/g><\/svg>\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1b09c20 elementor-widget elementor-widget-icon-box\" data-id=\"1b09c20\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2024\/09\/mr_fragebogen_ohne_schmerzdiagramm_metarad_fillable.pdf\" target=\"_blank\" >\n\t\t\t\t\t\t\tMRI-Fragebogen (PDF)\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tAusf\u00fcllbare PDF-Datei\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-65d235a e-flex e-con-boxed e-con e-parent\" data-id=\"65d235a\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-5151b54 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"5151b54\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;fadeIn&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7dcd62c fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"7dcd62c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-default fluentform_wrapper_4 ffs_default_wrap'><form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_4_1\" method=\"POST\" data-turnstile_key=\"0x4AAAAAAAjqZF2PnqEdqjr_\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Anmeldung online<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='5053' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"686795e6ee\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/5053\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_1\" ><h3>Personalien<\/h3><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_4_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Vorname\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_4_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Nachname\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Geschlecht\">Geschlecht<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8765b553d931d17ba417e3e354bfb0f2'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"weiblich\"  id='input_radio_8765b553d931d17ba417e3e354bfb0f2' aria-label='weiblich' aria-invalid='false' aria-required=false> <span>weiblich<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_dfb97c322bebe5ff76cb972195f976b8'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"m\u00e4nnlich\"  id='input_radio_dfb97c322bebe5ff76cb972195f976b8' aria-label='m\u00e4nnlich' aria-invalid='false' aria-required=false> <span>m\u00e4nnlich<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text' id='label_ff_4_input_text' aria-label=\"Strasse\">Strasse<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" placeholder=\"Strasse\" data-name=\"input_text\" id=\"ff_4_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_1' id='label_ff_4_input_text_1' aria-label=\"PLZ\/Ort\">PLZ\/Ort<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" placeholder=\"PLZ\/Ort\" data-name=\"input_text_1\" id=\"ff_4_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_2' id='label_ff_4_input_text_2' aria-label=\"Geburtsdatum\">Geburtsdatum<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" placeholder=\"Geburtsdatum\" data-name=\"input_text_2\" id=\"ff_4_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_3' id='label_ff_4_input_text_3' aria-label=\"Tel. privat\">Tel. privat<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" placeholder=\"Tel. privat\" data-name=\"input_text_3\" id=\"ff_4_input_text_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_4' id='label_ff_4_input_text_4' aria-label=\"Tel. mobil\">Tel. mobil<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" placeholder=\"Tel. mobil\" data-name=\"input_text_4\" id=\"ff_4_input_text_4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_5' id='label_ff_4_input_text_5' aria-label=\"Tel. gesch\u00e4ftlich\">Tel. gesch\u00e4ftlich<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" placeholder=\"Tel. gesch\u00e4ftlich\" data-name=\"input_text_5\" id=\"ff_4_input_text_5\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Kostenart\">Kostenart<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_9cc2a1f32b7d11a3aa63c5c816a2df3d'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Krankheit\"  id='input_radio_1_9cc2a1f32b7d11a3aa63c5c816a2df3d' aria-label='Krankheit' aria-invalid='false' aria-required=false> <span>Krankheit<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_24ac34d853e7a204a5d31481d1d08fc2'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Unfall\"  id='input_radio_1_24ac34d853e7a204a5d31481d1d08fc2' aria-label='Unfall' aria-invalid='false' aria-required=false> <span>Unfall<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_9796841d8c247534ba5d3f13e300d3d1'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"IV\"  id='input_radio_1_9796841d8c247534ba5d3f13e300d3d1' aria-label='IV' aria-invalid='false' aria-required=false> <span>IV<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_8141fdfa8fa4811a19269b08c7afae9f'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"MV\"  id='input_radio_1_8141fdfa8fa4811a19269b08c7afae9f' aria-label='MV' aria-invalid='false' aria-required=false> <span>MV<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_7' id='label_ff_4_input_text_7' aria-label=\"Kostentr\u00e4ger\">Kostentr\u00e4ger<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" placeholder=\"Kostentr\u00e4ger\" data-name=\"input_text_7\" id=\"ff_4_input_text_7\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_8' id='label_ff_4_input_text_8' aria-label=\"Versichertennummer\">Versichertennummer<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" placeholder=\"Versichertennummer\" data-name=\"input_text_8\" id=\"ff_4_input_text_8\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_9' id='label_ff_4_input_text_9' aria-label=\"AHV-Nummer\">AHV-Nummer<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" placeholder=\"AHV-Nummer\" data-name=\"input_text_9\" id=\"ff_4_input_text_9\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_2\" ><h3>Untersuchung<\/h3><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Untersuchung\">Untersuchung<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_bfcd0050e3f8916a4b9be302c6a59683'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"MRT\"  id='input_radio_2_bfcd0050e3f8916a4b9be302c6a59683' aria-label='MRT' aria-invalid='false' aria-required=false> <span>MRT<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_8f504af35e4da87e0514c82b65cba266'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"CT\"  id='input_radio_2_8f504af35e4da87e0514c82b65cba266' aria-label='CT' aria-invalid='false' aria-required=false> <span>CT<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_fd87ae59d8c49cb27b04fb6dc21478cf'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mammographie\"  id='input_radio_2_fd87ae59d8c49cb27b04fb6dc21478cf' aria-label='Mammographie' aria-invalid='false' aria-required=false> <span>Mammographie<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_ee2da93a80c793227b831f6471c1ab95'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Ultraschall\"  id='input_radio_2_ee2da93a80c793227b831f6471c1ab95' aria-label='Ultraschall' aria-invalid='false' aria-required=false> <span>Ultraschall<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_f00d7af4412d4284e1f78e404bb15155'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"R\u00f6ntgen\"  id='input_radio_2_f00d7af4412d4284e1f78e404bb15155' aria-label='R\u00f6ntgen' aria-invalid='false' aria-required=false> <span>R\u00f6ntgen<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_e6f573a72090b031cee5e13cd746a181'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Anderes\"  id='input_radio_2_e6f573a72090b031cee5e13cd746a181' aria-label='Anderes' aria-invalid='false' aria-required=false> <span>Anderes<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_10' id='label_ff_4_input_text_10' aria-label=\"Region\">Region<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" placeholder=\"Region\" data-name=\"input_text_10\" id=\"ff_4_input_text_10\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description' id='label_ff_4_description' aria-label=\"Anamnese\">Anamnese<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description\" name=\"description\" id=\"ff_4_description\" class=\"ff-el-form-control\" placeholder=\"Anamnese\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_1' id='label_ff_4_description_1' aria-label=\"Fragestellung\">Fragestellung<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_1\" name=\"description_1\" id=\"ff_4_description_1\" class=\"ff-el-form-control\" placeholder=\"Fragestellung\" rows=\"3\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_3\" ><h3>Angaben Zuweiser<\/h3><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_11' id='label_ff_4_input_text_11' aria-label=\"Datum\">Datum<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" placeholder=\"Datum\" data-name=\"input_text_11\" id=\"ff_4_input_text_11\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_12' id='label_ff_4_input_text_12' aria-label=\"Arzt\">Arzt<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" placeholder=\"Arzt\" data-name=\"input_text_12\" id=\"ff_4_input_text_12\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_13' id='label_ff_4_input_text_13' aria-label=\"Praxis\/Adresse\">Praxis\/Adresse<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" placeholder=\"Praxis\/Adresse\" data-name=\"input_text_13\" id=\"ff_4_input_text_13\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Termin\">Termin<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_58e2ceb8e8bdbe5dd3543a76ea03d035'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Patient aufbieten\"  id='input_radio_3_58e2ceb8e8bdbe5dd3543a76ea03d035' aria-label='Patient aufbieten' aria-invalid='false' aria-required=false> <span>Patient aufbieten<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_75b931384c641f4a015b9ba04fb46425'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Patient hat Termin\"  id='input_radio_3_75b931384c641f4a015b9ba04fb46425' aria-label='Patient hat Termin' aria-invalid='false' aria-required=false> <span>Patient hat Termin<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_2' id='label_ff_4_description_2' aria-label=\"Bemerkungen\">Bemerkungen<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_2\" name=\"description_2\" id=\"ff_4_description_2\" class=\"ff-el-form-control\" placeholder=\"Bemerkungen\" rows=\"3\" cols=\"2\" data-name=\"description_2\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_3' id='label_ff_4_description_3' aria-label=\"Befundkopie an:\">Befundkopie an:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_3\" name=\"description_3\" id=\"ff_4_description_3\" class=\"ff-el-form-control\" placeholder=\"Befundkopie an:\" rows=\"3\" cols=\"2\" data-name=\"description_3\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"\u00dcbermittlung\">\u00dcbermittlung<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_cdfd9c4a908f8d37cfe4251593c8a3d8'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"via Uploadlink\"  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